Spinal Flow Adult Intake Form

Please take a moment to complete the form below. All information shared is strictly confidential and viewed only by you and your practitioner.

This is a safe, sacred space for your healing. The information you provide helps us understand what may be held emotionally, physically, and chemically within your body. It also gives us a clear baseline to track your progress as your nervous system begins to unwind and realign.

Let’s begin your journey toward balance, flow, and renewal. 🌙

First name

Last name

Email

Phone

Birthday

Month

Day

Year

Occupation

Emergency Contact's Name & Phone Number:

Have you had a Spinal Flow done before?

Yes

No

About Your Health

Your body is inherently intelligent and designed to heal. However, throughout life, various experiences—physical, emotional, and chemical—can impact this natural flow of health and vitality.

This form helps us uncover the layers of stored tension and imbalance within your nervous system so we can better understand what may be influencing your current state of well-being. During your Spinal Flow journey, we’ll begin gently releasing these layers, allowing your body to reconnect with its innate healing potential.

Early Life (Birth – Age 5)

Let’s begin at the very start of your journey. The first years of life play a powerful role in shaping the nervous system and overall wellness. Reflecting on this time can help us identify early patterns or experiences that may have influenced how your body holds and expresses energy today.

Was your mother's delivery with you long and/or diﬃcult?

Yes

No

Unsure

Were Forceps or suction used?

Yes

No

Unsure

Was the birth Cesarean? (C-Section)

Yes

No

Unsure

Breech / Cephalic?

Yes

No

Unsure

Did you have colic, reflux or diﬃculty feeding?

Yes

No

Unsure

Were there any stressful or challenging circumstances your mother, father, or family may have experienced during your early childhood (ages 0–5)?

From ages 0-5, did you experience any physical injuries (such as falls or accidents), illnesses, or emotionally stressful or traumatic events that may have influenced your overall health or development?

If you’re aware of any early experiences that may have shaped how your body or nervous system responds to stress, please share what feels relevant or significant to you.

Shifts in Health & Vitality (Age 5 – Present)

As life unfolds, various experiences—physical, emotional, and environmental—can influence how the body expresses health. Over time, these layers may build, showing up as symptoms, tension, or cycles of imbalance that signal where the body is seeking to restore harmony.

Please list all medications, prescriptions, substances & or supplements you are currently using and their frequency below. (Anything in the last 2 months.)

Diet (do you eat healthy?)

Yes - I consistently Eat Healthy

No- my diet is not healthy & I can make positive change there.

Please list any accidents, injuries, surgeries, or organs that were removed & give details/timelines about the events.

Sleeping Position

Stomach

Back

Side

Did you / Do you have Occupational stress? (Major situations/events from age 5-Now)

Physical and/or Mental stress? (Major situations/events from age 5-Now)

Do you exercise? If so, how frequently & what forms of exercise do you do?

Present State Of Health

Let's do a mindful check-in! Close your eyes, take a few deep breaths, and answer the following questions with intention. Please provide as much detail and transparency as possible, the more we know about your life, experiences & perspective, the more you will get out of your spinal flow sessions!

Please explain and describe what is the main reason/s you are here? What symptoms are you currently experiencing? When did this start? and what do you think the cause is?

What aggravates or worsens the above symptoms?

What improves or lessens the above symptoms?

On a scale of 1-10, how happy are you? 1=Very Unhappy. 10=Very Happy (think about the last 2 weeks).

On a scale of 1-10, how stressed are you? 1=Not Stressed. 10=Very Stressed (think about the last 2 weeks).

On a scale of 1-10, how much energy do you have? 1=No Energy. 10=Very High Energy (think about the last 2 weeks).

If those symptoms were to go away tomorrow, what would be different about your life?

What are you looking to get out of these sessions?

Please let us know in a few sentences, how I can support you during session & help you the most?

By signing this form, I voluntarily consent to receive Spinal Flow Technique sessions from Jordyn Kurtz, practitioner and owner of Astralis Healing.

I understand that Jordyn Kurtz is not a licensed medical or healthcare professional, and that Spinal Flow Technique is a complementary, holistic modality designed to support the body’s natural healing processes.

Understanding & Agreement

Your Signature

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Today's Date

I have read and agree to the Astralis Healing Spinal Flow Client Consent & Disclaimer, and I understand that by signing, I am voluntarily consenting to services and releasing certain legal claims as outlined.

I agree to the terms & conditions.

Adult Spinal Flow Technique Consent & Liability Waiver

Spinal Flow Adult Intake Form

About Your Health

Early Life (Birth – Age 5)

Shifts in Health & Vitality (Age 5 – Present)

Present State Of Health

Understanding & Agreement

Adult Spinal Flow Technique
Consent & Liability Waiver